Registered Nurse, Care Manager - Enhanced Care Management

ABOUT US:

Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together.

As a private, non-profit 501(C) (3) community health organization, we serve over 500,000 medical, dental, and behavioral health visits from more than 100,000 people annually. We do this in pursuit of our mission to improve the health and happiness of the communities we serve by providing quality care to all, regardless of situation or circumstance.

We have been doing this since 1969 and it is our employees that make this mission a reality. Regardless of the role, our team focuses on being compassionate, having integrity, being professional, always collaborating, and consistently going above and beyond. If that sounds like an organization you want to be a part of, we would love to have you.

ROLE OVERVIEW and PURPOSE:

The RN Care Manager supports Enhanced Care Management (ECM) patients with complex medical conditions and completes medication reconciliation with pharmacies for all ECM-enrolled patients. This role will provide care coordination and connection to services and social support for ECM patients, including appointment scheduling and referral management. In addition, this role will require travel to Neighborhood Healthcare sites for designated meetings and trainings. This is a hybrid position, however, on-site expectations are dependent on performance.

RESPONSIBILITIES:

• Manages a caseload of patients with complex medical needs
• Engages, supports, and encourages patient activation towards achieving health goals
• Tracks medical and behavioral health outcomes in the web-based care management platform and patient electronic health information platform
• Improves health literacy by providing chronic medical and behavioral health education to patients and families
• Prioritizes patient cases for systematic population and caseload review by gathering input from ECM team members
• Facilitates communication between patients and providers by identifying health and wellness goals to incorporates into health action and shared care plans
• Coordinates physical care management and care coordination relationships with external healthcare providers
• Receives, identifies, and follows-up with treatment and medication alerts
• Consults with the ECM team members about clinical concerns and questions
• Ensures smooth transitions of care by coordinating patient admission and discharges with hospitals
• Conducts medication reconciliations with input from the providers
• Tracks and assures required assessments and screenings are performed, including comprehensive health assessments and shared care plans
• Reviews adult comprehensive health assessments upon completion by other care team members

Quality Management & Record Keeping

• Contributes to the success of the organization by participating in quality improvement activities
• Documents all patient care coordination, education, and other services in the ECW
• Prioritizes activities according to intensity, need, and required follow-up
• Provides accurate and timely reports to management, as needed

Pediatric RN Care Manager Duties Only

• Assist individuals and families in improving their quality of life by ensuring access to basic needs such as medical care, food, behavioral health, and safety
• Conduct one-on-one counseling with high-risk pediatric and adult patients

• Associate's degree in nursing required, Bachelor's degree in nursing preferred
• California Registered Nurse license required
• Current Basic Life Support (BLS) certification though an American Heart Association (AHA)-approved source is required upon hire and must be maintained as a condition of employment
  • AHA-approved courses include an in-person, hands-on skills check with a certified instructor using a mannequin to demonstrate CPR and emergency response techniques
  • Online-only BLS courses without a live skills check do not meet this requirement
• Valid California driver’s license or out of state driver’s license for active military personnel/spouses required
• Proof of auto insurance required
• 2 years of clinical, outpatient, or general medicine experience preferred
• Bilingual (English/Spanish) preferred
• 3 years of experience in nursing or case management required
• Experience with community outreach, behavioral health, working with high-risk and/or pediatric populations is required

ADDITIONAL QUALIFICATIONS (Knowledge, Skills and Abilities):

• Excellent verbal and written communication skills, including superior composition, typing and proofreading skills
• Ability to work with Microsoft applications, such as Excel and Word
• Ability to interpret a variety of instructions in written, oral, diagram, or schedule form
• ability to interact effectively with clinic personnel, patients, and community-based organizations
• Knowledgeable about and experience social and health issues
• Knowledgeable about and experience with evidenced based communication such as Motivational Interviewing, or similar empathy-based communication strategies (emotional intelligence)
• Excellent interpersonal and conflict resolution skills
• Ability to sufficiently engage patients and providers both on the phone and in person
• Knowledge about sensitivity to multi-cultural community, mental health conditions, and addictive disorders
• Awareness of the impact of unmitigated bias and judgement on health; commitment to addressing both
• Ability to successfully manage multiple tasks simultaneously
• Excellent planning and organizational ability
• Ability to work as part of a team as well as independently
• Ability to work with highly confidential information in a professional and ethical manner

Physical Requirements

• Ability to lift/carry 25 lbs/weight
• Ability to stand for long periods of time

Pay Range: $45.9135 to $67.93 per hour, depending on experience. This role is eligible for a $2,500 signing bonus.

Compensation Disclosure: The posted salary range reflects the designated pay grade for this position. While this range represents the broader classification of the role, actual compensation will be based on several factors, including but not limited to: the candidate’s overall knowledge, skills, and experience, market data and industry benchmarks, internal equity within the organization, Budgetary considerations and organizational needs. As a result, placement within the range is not guaranteed, and the full pay grade range may not be utilized.